Morbidity and Mortality Weekly Report Recommendations and Reports February 1, 2002 / Vol. 51 / No. RR-1 Centers for Disease Control and Prevention Centers for Disease Control and Prevention Centers for Disease Control and Prevention Centers for Disease Control and Prevention Centers for Disease Control and Prevention SAFER • HEAL SAFER • HEAL SAFER • HEAL SAFER • HEAL SAFER • HEALTHIER • PEOPLE THIER • PEOPLE THIER • PEOPLE THIER • PEOPLE THIER • PEOPLE TM Community Interventions to Promote Healthy Social Environments: Early Childhood Development and Family Housing A Report on Recommendations of the Task Force on Community Preventive Services
Transcript
Morbidity and Mortality Weekly Report
Recommendations and Reports February 1, 2002 / Vol. 51 / No. RR-1
Centers for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionSAFER • HEALSAFER • HEALSAFER • HEALSAFER • HEALSAFER • HEALTHIER • PEOPLETHIER • PEOPLETHIER • PEOPLETHIER • PEOPLETHIER • PEOPLETM
Community Interventionsto Promote Healthy Social Environments:
Early Childhood Development and Family Housing
A Report on Recommendations of the Task Forceon Community Preventive Services
Use of the Recommendations in Communities ..................... 6
Additional Information Regarding the Community Guide ...... 8
References ........................................................................... 8SUGGESTED CITATIONCenters for Disease Control and Prevention.Community interventions to promote healthy socialenvironments: early childhood development andfamily housing. MMWR 2002;51(No. RR-1):[inclusive page numbers].
The MMWR series of publications is published by theEpidemiology Program Office, Centers for DiseaseControl and Prevention (CDC), U.S. Department ofHealth and Human Services, Atlanta, GA 30333.
Centers for Disease Control and Prevention
Jeffrey P. Koplan, M.D., M.P.H.Director
David W. Fleming, M.D.Deputy Director for Science and Public Health
Dixie E. Snider, Jr., M.D., M.P.H.Associate Director for Science
Epidemiology Program Office
Stephen B. Thacker, M.D., M.Sc.Director
Office of Scientific and Health Communications
John W. Ward, M.D.Director
Editor, MMWR Series
Suzanne M. Hewitt, M.P.A.Managing Editor
Natalie R. CarringtonProject Editor
Beverly J. HollandVisual Information Specialist
Michele D. RenshawErica R. Shaver
Information Technology Specialists
Vol. 51 / RR-1 Recommendations and Reports 1
BackgroundSociocultural factors are important determinants of health
(1–3 ). Sociocultural determinants of health include societalresources (e.g., social institutions, economic systems, politicalstructures), physical surroundings (e.g., neighborhoods, work-places, built environments), and social relationships (4 ). Rec-ognition that health is a product of social conditions facilitatesidentification of social determinants that might be amenable
Community Interventions to Promote Healthy Social Environments:Early Childhood Development and Family Housing
A Report on Recommendations of the Task Forceon Community Preventive Services
Prepared byLaurie M. Anderson, Ph.D., M.P.H., Carolynne Shinn, M.S., Joseph St. Charles, M.P.A.
Division of Prevention Research and Analytic Methods, Epidemiology Program Officein collaboration with
Mindy T. Fullilove, M.D.Task Force on Community Preventive Services and Columbia University
Susan C. Scrimshaw, Ph.D.Task Force on Community Preventive Services and School of Public Health, University of Illinois, Chicago
Jonathan E. Fielding, M.D., M.P.H., M.B.A.Task Force on Community Preventive Services, Los Angeles Department of Health Services,
and School of Public Health, University of California, Los AngelesJacques Normand, Ph.D.
National Institute on Drug Abuse, National Institutes of HealthRuth Sanchez-Way, Ph.D.
Community Substance Abuse Prevention, Substance Abuse and Mental Health Services AdministrationTodd Richardson
Division of Research and Evaluation, U.S. Department of Housing and Urban Development
Summary
The sociocultural environment exerts a fundamental influence on health. Interventions to improve education, housing, employ-ment, and access to health care contribute to healthy and safe environments and improved community health. The Task Force onCommunity Preventive Services (the Task Force) has conducted systematic reviews of early childhood development interventionsand family housing interventions. The topics selected provide a unique, albeit small, beginning of the review of evidence thatinterventions do effectively address sociocultural factors that influence health. Based on these reviews, the Task Force stronglyrecommends publicly funded, center-based, comprehensive early childhood development programs for low-income children aged3–5 years. The basis for the recommendation is evidence of effectiveness in preventing developmental delay, assessed by improve-ments in grade retention and placement in special education. The Task Force also recommends housing subsidy programs for low-income families, which provide rental vouchers for use in the private housing market and allow families choice in residentiallocation. This recommendation is based on outcomes of improved neighborhood safety and families’ reduced exposure to violence.The Task Force concludes that insufficient evidence is available on which to base a recommendation for or against creation ofmixed-income housing developments that provide safe and affordable housing in neighborhoods with adequate goods and services.This report provides additional information regarding these recommendations, briefly describes how the reviews were conducted,and discusses implications for applying the interventions locally.
to community interventions that can lead to improved healthoutcomes. These interventions might also reduce the persis-tent disparities in health related to socioeconomic status, edu-cation, and housing.
Early Childhood DevelopmentChild development is a powerful determinant of health in
adult life as indicated by the strong relationship between mea-
2 MMWR February 1, 2002
sures of educational attainment and adult disease (5 ). Theperiod of child development from birth to age 5 years is criti-cal for normal brain development and establishment of a foun-dation for adult cognitive and emotional function (6 ). Inaddition to frequently cited risk factors for developmentaldysfunction (e.g., premature birth, low birth weight, sequelaeof childhood infections, and lead poisoning), exposure to animpoverished environment is recognized as a sociocultural riskfactor (6,7 ). Because access to resources mediates the effectsof adverse sociocultural conditions, children in poverty areespecially vulnerable (7 ). Poverty in the United States is high-est among children. Despite periodic declines in child povertyduring the last 40 years, the rate increased from 17.6% to19.7% during 1966–1997 (8 ). Low socioeconomic statusduring childhood interferes with cognitive and behavioraldevelopment and is a modifiable risk factor for lack of readi-ness for school (9 ). Head Start (a national preschool educa-tion program designed to prepare children from disadvantagedbackgrounds for entrance into formal education in the pri-mary grades) is an example of a feasible program that coulddiminish harm to young children from disadvantagedenvironments (10 ).
Housing and HealthThe social, physical, and economic characteristics of neigh-
borhoods also are increasingly recognized as having both short-and long-term consequences for residents’ quality and yearsof healthy life (11,12 ). Among the most prevalent commu-nity health concerns related to family housing are the inad-equate supply of affordable housing for low-income personsand the increasing spatial segregation of households by in-come, race, ethnicity, or social class into unsafe neighborhoods(13 ). The increasing concentration of poverty can result inphysical and social deterioration of neighborhoods as indi-cated by housing disinvestment and deteriorated physical con-ditions and a reduction in the ability of formal and informalinstitutions to maintain public order. The ability of informalnetworks to disseminate information regarding employmentopportunities and available health resources and promotehealthy behaviors and positive life choices might decline aswell (14 ).
When affordable housing is unavailable to low-incomehouseholds, family resources needed for food, medical or dentalcare, and other necessities are diverted to housing costs. Resi-dential instability results, as families are forced to move fre-quently, live with other families in overcrowded conditions,or experience periods of homelessness. Residential instabilityis associated with children’s poor attendance and performancein school, no primary source of medical care, lack of preven-tive health services (e.g., child immunizations), various acute
and chronic medical conditions, sexual assault, andviolence (15,16 ).
Various policies and programs are available to improve com-munity health outcomes. Two such programs were reviewed:the Department of Housing and Urban Development (HUD)Section 8 Housing Voucher Program and the creation of mixed-income housing developments.
IntroductionThis MMWR report is one in a series of topics to be com-
pleted for the Guide to Community Preventive Services (theCommunity Guide), a resource that will include multiple chap-ters, each focusing on a preventive health topic. This reportprovides an overview of the process used by the Task Force onCommunity Preventive Services (the Task Force) to select andreview evidence and summarizes the recommendations of theTask Force regarding community interventions that promotehealthy social environments. A full report of the recommen-dations, supporting evidence (i.e., applicability, additionalbenefits, potential harms, barriers to implementation), cost-effectiveness of the interventions (where available), and remain-ing research questions will be published in the American Journalof Preventive Medicine later this year.
The independent, nonfederal Task Force is developing theCommunity Guide with the support of the U.S. Departmentof Health and Human Services (DHHS) in collaboration withpublic and private partners. CDC provides staff support tothe Task Force for development of the Community Guide.However, the recommendations presented in this report weredeveloped by the Task Force and are not necessarily the rec-ommendations of CDC or DHHS.
MethodsThe Community Guide’s methods for conducting sys-
tematic reviews and linking evidence to recommendationshave been described elsewhere (17 ). In brief, for eachCommunity Guide topic, a multidisciplinary team conductsreviews by
• developing an approach to organizing, grouping, and se-lecting interventions for review;
• systematically searching for and retrieving evidence;• assessing the quality of and summarizing the strength of
the body of evidence of effectiveness;• summarizing information regarding other evidence; and• identifying and summarizing research gaps.For this report, a multidisciplinary review team (the team)
consisting of a coordination team (the authors) and a consul-
Vol. 51 / RR-1 Recommendations and Reports 3
tation team* developed a conceptual framework that identi-fies determinants of health in the social environment, healthoutcomes influenced by those determinants, and points be-tween determinants and outcomes where community inter-ventions might have positive effects. After polling consultantsand other specialists in the field regarding the importance ofvarious interventions for improving the health of communi-ties, the review team created an extensive list of interventionsand subsequently created a priority list of interventions forreview.
For early childhood development, the team focused on pub-licly funded, center-based, comprehensive preschool programsdesigned to promote the cognitive and social development ofchildren aged 3–5 years at risk because of poverty. To be in-cluded in the reviews of effectiveness, studies had to a) docu-ment an evaluation of an early childhood development programwithin the United States; b) be published in English since 1965;c) compare outcomes among groups of persons exposed to theintervention with outcomes among groups of persons not ex-posed to the intervention (whether the comparison was con-current between groups or before-after within groups); and d)report a relevant outcome measure. Relevant outcomes were
a) cognitive (academic achievement, IQ scores, grade reten-tion rates, placement in special education, and school readi-ness); b) social (child behavioral assessments, teen parenting,high school graduation, employment, use of social services,delinquency, arrests, and incarceration); c) health (healthscreening, preventive services, and dental care); d) family (pa-rental educational attainment, employment of parents, familyincomes above poverty level, receipt of public assistance, andsiblings’ use of preventive care).
Included in this report are selected National Education Goalsand Healthy People 2010 goals and objectives that highlightthe intersection of health and cognitive outcomes related toearly childhood development (Table 1). Selected goals andobjectives from HUD and Healthy People 2010 related to hous-ing programs that reduce residential segregation by income,race, or ethnicity are also included (Table 2). Among programsthat provide families with affordable housing, the team se-lected for review, based on the priority-setting exercise describedabove, two that are intended to decrease residential segrega-tion by socioeconomic status. The creation of mixed-incomehousing developments has potential as an effective methodfor increasing local socioeconomic heterogeneity and prevent-
* Members of the consultation team were Regina M. Benjamin, M.D., M.B.A., Bayou La Batre Rural Health Clinic, Bayou La Batre, Alabama; David Chavis, Ph.D.,Association for the Study and Development of Community, Gaithersburg, Maryland; Shelly Cooper-Ashford, Center for Multicultural Health, Seattle, Washington;Leonard J. Duhl, M.D., School of Public Health, University of California, Berkeley, California; Ruth Enid-Zambrana, Ph.D., Department of Women’s Studies, Universityof Maryland, College Park, Maryland; Stephen B. Fawcette, Ph.D., Work Group on Health Promotion and Community Development, University of Kansas, Lawrence,Kansas; Nicholas Freudenberg, Dr.P.H., Urban Public Health, Hunter College, City University of New York, New York, New York; Douglas Greenwell, Ph.D., TheAtlanta Project, Atlanta, Georgia; Robert A. Hahn, Ph.D., M.P.H., Epidemiology Program Office, CDC, Atlanta, Georgia; Camara P. Jones, M.D., Ph.D., M.P.H., NationalCenter for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia; Joan Kraft, Ph.D., National Center for Chronic Disease Prevention and HealthPromotion, CDC, Atlanta, Georgia; Nancy Krieger, Ph.D., School of Public Health, Harvard University, Cambridge, Massachusetts; Robert S. Lawrence, M.D., BloombergSchool of Public Health, Johns Hopkins University, Baltimore, Maryland; David V. McQueen, National Center for Chronic Disease Prevention and Health Promotion,CDC, Atlanta, Georgia; Jesus Ramirez-Valles, Ph.D., M.P.H., School of Public Health, University of Illinois, Chicago, Illinois; Robert Sampson, Ph.D., Social SciencesDivision, University of Chicago, Chicago, Illinois; Leonard S. Syme, Ph.D., School of Public Health, University of California, Berkeley, California; David R. Williams,Ph.D., Institute for Social Research, University of Michigan, Ann Arbor, Michigan.
TABLE 1. Selected National Education Goals and objectives and Healthy People 2010 goals and objectives related to earlychildhood development
* US Department of Education. Available at http://www.ed.gov/legislation/GOALS2000/TheAct/sec102.html. Accessed October 2, 2001.†US Department of Health and Human Services. Healthy People 2010, vols I and II. 2nd ed. Washington, DC: US Government Printing Office, November2000.
National Education Goals and Objectives*
Goal 1: By the year 2000, all children will start school ready to learn.
Objectives: Children will receive the nutrition, physical activityexperiences, and health care needed to arrive at school with healthy mindsand bodies, and to maintain the mental alertness necessary to be preparedto learn. The number of low-birth-weight babies will be significantlyreduced through enhanced prenatal health systems.
All children will have access to high-quality and developmentallyappropriate preschool programs that help prepare children for school
Goal 2: By the year 2000, the high school graduation rate will increase toat least 90%.
Healthy People 2010 Goals and Objectives †
Maternal and Child Health Goal: Improve the health and well-being ofwomen, infants, children, and families.
Prenatal Care Objectives: Increase the proportion of pregnant womenwho receive early and adequate prenatal care (objective 16–6).
Risk Factor Objectives: Reduce low birth weight (LBW) and very lowbirth weight (VLBW) (objective 16–10). Reduce the occurrence ofdevelopmental disabilities (objective 16–14).
Education and Community-Based Programs Goal: Increase thequality, availability and effectiveness of educational and community-basedprograms designed to prevent disease and improve health and quality oflife.
School Setting Objective: Increase high school completion. Target: 90%(objective 7–1).
ing or reversing neighborhood physical and social deteriora-tion while expanding the supply of decent, affordable hous-ing. Tenant-based rental assistance was selected as a methodfor providing housing assistance to low-income householdsby allowing assisted households choice in selecting private-market rental units in higher-income neighborhoods.
To be included in the reviews of effectiveness, studies hadto a) document an evaluation of a mixed-income housing de-velopment or a tenant-based rental voucher program for fami-lies within the United States; b) be published in English since1965; c) compare outcomes among groups of persons exposedto the intervention with outcomes among groups of personsnot exposed to the intervention (whether the comparison wasconcurrent between groups or before-after within groups); andd) report a relevant outcome measure. Relevant outcomes werea) housing hazards (substandard housing conditions that posehealth and safety risks); b) neighborhood safety (intentionalinjuries, victimization from crime, crime against person andproperty, and social disorder); c) youth risk behaviors (behav-ioral problems in school and at home, dropping out of school,delinquency, and arrests); d) mental or physical health status(physical or psychological morbidity and unintentional injury).To ascertain implementation of the program, data were also
collected regarding the percentage of household income spenton housing and on socioeconomic heterogeneity of housingdevelopment residents (for mixed-income housing develop-ments) or of neighborhood (for rental voucher programs).
For each intervention reviewed, the team developed an ana-lytic framework indicating possible causal links between theintervention studied and the predetermined outcomes of in-terest. Outcomes of interest for early childhood developmentprograms were gains in intellectual ability, social cognition,social and health risk behaviors (e.g., disruptive behavior inschool, school drop-out, substance abuse, teen pregnancy),use of preventative services (e.g., immunizations, health screen-ings, and dental exams), and family’s use of health promotionprograms. Outcomes of interest for housing interventions werehousing hazards (e.g., peeling lead paint, mold, rodent infes-tation), neighborhood safety and physical disorder (e.g., crime,victimization, public drinking or drug use, abandoned build-ings, trash), social isolation, and social and health risks (e.g.,unemployment, school drop-out rates, measures of mental andphysical health status). To make a recommendation, the TaskForce required a sufficient number of studies, a consistent ef-fect, and a sufficient effect size for at least one outcome (either
TABLE 2. Selected U.S. Department of Housing and Urban Development (HUD) goals and objectives and Healthy People 2010goals and objectives related to housing programs that reduce residential segregation by income.
*US Department of Housing and Urban Development. FY2000-FY2006 Strategic Plan. September 2000. Available at http://www.hud.gov/reform/strategicplan.pdf. Accessed December 4, 2001.
†US Department of Health and Human Services. Healthy People 2010, vols I and II. 2d ed. Washington, DC: US Government Printing Office, November2000.
HUD FY2000-FY2006 Strategic Plan *
Goal 1: Increase the availability of decent, safe and affordable housingin American communities.
Objective 1.2 Performance Measurement: By 2005, the number offamilies with children, elderly households and persons with disabilitieswith worst case housing needs will decrease by 30 percent from the1997 levels.
Goal 2: Ensure equal opportunity in housing for all Americans.
Objective 2.2 Performance Measurement: Segregation of racial andethnic minorities and low-income households will decline.
Goal 3: Promote housing stability, self-sufficiency and asset develop-ment of families and individuals.
Objective 3.2 Performance Measurement: The annual percentagegrowth in earnings of families in public and assisted housing increases.
Goal 4: Improve community quality of life and economic vitality.
Objective 4.2 Performance Measurement: The share of all house-holds located in neighborhoods with extreme poverty decreases.
Objective 4.3 Performance Measurements: Among low- andmoderate-income residents, the share with a good opinion of theirneighborhood increases for cities, suburbs, and non-metropolitan areas.Residents of public housing are more satisfied with their safety.
Healthy People 2010 Goals and Objectives †
Educational and Community-Based Programs Goal: Increase thequality, availability, and effectiveness of educational and community-based programs designed to prevent disease and improve health andquality of life.
Community Setting Objective: (Developmental) Increase theproportion of Tribal and local health service areas or jurisdictions thathave established a community health promotion program that ad-dresses multiple Healthy People 2010 focus areas (objective 7-10).
Environmental Health Goal: Promote health for all through a healthyenvironment.
Healthy Homes and Healthy Communities Objective: Reduce theproportion of occupied housing units that are substandard (objective 8-23).
Injury and Violence Prevention Goal: Reduce injuries, disabilities,and deaths due to unintentional injuries and violence.
Violence and Abuse Prevention Objectives: Reduce homicides(objective 15-32). Reduce the annual rate of rape or attempted rape(objective 15-35). Reduce sexual assault other than rape (objective 15-36). Reduce physical assaults (objective 15-37).
a health outcome or a more proximal outcome closely linkedto a health outcome) (17 ).
For early childhood development programs, searches wereconducted in five computerized databases — PsychInfo, Edu-cational Resource Information Center (ERIC), Medline, So-cial Science Search, and the Head Start Bureau researchdatabase.† Published annotated bibliographies on Head Startand other early childhood development research, reference listsof reviewed articles, meta-analyses, and Internet resources werealso examined, as were referrals from specialists in the field.
For family housing programs, searches were conducted inten computerized databases — Avery Index to ArchitecturalPeriodicals, EBSCO Information Services’ Academic Search™Elite, HUD User Bibliographic Database, MarciveWeb Cata-logue of U.S. Government Publications, ProQuest Disserta-tions, ProQuest General Research Databases, PsychInfo, PublicAffairs Information Services, Social Sciences Citation Index,and Sociological Abstracts.§ Internet resources were examined,as were reference lists of reviewed articles and referrals fromspecialists in the field.
Each study that met the inclusion criteria was evaluated us-ing a standardized abstraction form and assessed for suitabil-ity of the study design and threats to validity (18 ). On thebasis of the number of threats to validity, studies were charac-terized as having good, fair, or limited execution. Results oneach outcome of interest were obtained from each study thatmet the minimum quality criteria. Where possible, for studiesthat reported multiple measures of a given outcome, the “best”measure with respect to validity and reliability was chosen ac-cording to consistently applied rules. Measures that were ad-justed for the effects of potential confounders were used inpreference to crude effect measures. For studies in which ad-justed results were not provided, net effects were derived whenpossible by calculating the difference between the changes ob-served in the intervention and comparison groups. Amongsimilar effect measures, the median was calculated as a sum-mary measure.
The strength of the body of evidence of effectiveness wascharacterized as strong, sufficient, or insufficient on the basisof the number of available studies, the suitability of study de-signs for evaluating effectiveness, the quality of execution of
the studies, the consistency of the results, and the effect size(17 ). The Task Force recognizes that a body of relevant socialscience literature was excluded from the reviews of effective-ness reported here because it lacked relevant comparisons. Theexcluded literature is rich and valuable for several purposes,such as assessing the need for programs, generating hypoth-eses, describing programs, assessing the fidelity with whichprograms were implemented, and many others. However, theTask Force thought this literature was less reliable for attribut-ing effects to programmatic efforts and it was therefore notthe primary focus of this review. Nonetheless, considerableuse of the excluded literature in choosing topics, developinglogic and analytic frameworks, and providing implementationadvice has been made.
The Task Force makes recommendations based on the find-ings of the systematic reviews. The strength of each recom-mendation is based on the strength of the evidence ofeffectiveness (e.g., an intervention is strongly recommendedwhen strong evidence of effectiveness exists, and an interven-tion is recommended when sufficient evidence exists) (17 ).Other types of evidence can also affect a recommendation.For example, evidence of harms resulting from an interven-tion might lead to a recommendation that the interventionnot be used if adverse effects outweigh improved outcomes.
A finding of insufficient evidence of effectiveness does notresult in recommendations for or against an intervention’s use,but is important for identifying areas of uncertainty and re-search needs. In contrast, sufficient or strong evidence of inef-fectiveness leads to a recommendation that the interventionnot be used.
ResultsFor early childhood development, the literature search
yielded a list of 2,100 articles, of which 350 were assessed forinclusion. A total of 57 articles meeting the inclusion criteria(i.e., studied a relevant intervention, had a comparative studydesign, and reported on one or more outcomes relevant to theearly childhood development analytic framework) was obtainedand evaluated. Of these, 40 were excluded on the basis of threatsto validity or because they duplicated information provided
†These databases can be accessed as follows: PsychInfo: DIALOG, http://dialogclassic.com (requires id/password account), http://www.apa.org/psycinfo/products/psycinfo.html; ERIC: http://www.askeric.org/Eric/; Medline: http://www.ncbi.nlm.nih.gov/PubMed/; SocSci Search: DIALOG http://dialogclassic.com (requiresid/password account); http://www.isinet.com/isi/products/citation/ssci/index.html; Head Start Bureau: http://www2.acf.dhhs.gov/programs/hsb/.
§ These databases can be accessed as follows: Avery Index: DIALOG http://dialogclassic.com (requires id/password account), http://www.columbia.edu/cu/libraries/indexes/avery-index.html; EBSCO: GALILEO http://galileo.gsu.edu (requires id/password), http://www.epnet.com/database.html#af; HUD UserBibliographic Database: http://www.huduser.org/bibliodb/pdrbibdb.html; MarciveWeb Catalogue: http://www.marcive.com/HOMEPAGE/web7.htm; ProQuestDissertations: http://wwwlib.umi.com/dissertations/; ProQuest General Research: http://www.proquest.com/proquest/; PsychInfo: DIALOG, http://dialogclassic.com (requires id/password account), http://www.apa.org/psycinfo/products/psycinfo.html; Public Affairs Information Services: DIALOG, http://dialogclassic.com (requires id/password account), http://www.pais.org/products/index.stm; Social Sciences Citation Index: DIALOG http://dialogclassic.com(requires id/password account), http://www.isinet.com/isi/products/citation/ssci/index.html; Sociological Abstracts: DIALOG http://dialogclassic.com (requiresid/password account), http://www.csa.com/detailsV5/socioabs.html.
in another included study. The remaining 17 studies were con-sidered qualifying studies on which the Task Force recom-mendation is based. All of the qualifying studies had good orfair quality of execution.
The Task Force strongly recommends publicly funded, cen-ter-based, comprehensive early childhood development pro-grams for children aged 3–5 years, at risk because of poverty,on the basis of the strong evidence of effectiveness for improv-ing cognitive outcomes of grade retention and placement inspecial education (Table 3). Although the Task Force made norecommendation based on other outcomes, members notedthe remarkable and positive long-term effects (e.g., reducedteen pregnancy, completion of high school, employment, homeownership, and reduced arrests and incarceration) from theHigh/Scope Perry Preschool Program (19 ). However, this in-tervention differed from other early childhood developmentprograms in terms of quality and implementation support,and results could not be generalized to other programs such asHead Start.
For the review of mixed-income housing developments, thereview team examined 312 citations (titles and abstracts) iden-tified through the database search, review of pertinent refer-ence lists, and consultation with housing specialists. A total of41 articles, reports, and dissertations were obtained, but nonemet the inclusion criteria (i.e., studied a relevant intervention,had a comparative study design, and reported on one or moreoutcomes relevant to the analytic framework). As a result, in-sufficient evidence existed on which the Task Force could basea recommendation for or against the use of this intervention.This lack of evidence does not mean that this intervention isineffective, but does indicate the need for well-designed evalu-ations of such interventions, which would allow assessment oftheir effectiveness.
For the review of tenant-based rental voucher programs, theliterature searches yielded 509 citations, of which 56 wereobtained and evaluated for inclusion based on a relevant in-tervention, a comparative study design, and a report of rel-evant outcomes. A total of 23 articles and reports qualified forevidence review. Based on consistency of effect and sufficienteffect size, the Task Force recommends the use of rental voucherprograms to improve household safety by providing familieschoice in moving to neighborhoods with reduced exposure toviolence (Table 3).
Use of the Recommendationsin Communities
Interventions that improve children’s opportunities to learnand develop capacity should be relevant to all communities.
These interventions are particularly important for children incommunities with high rates of poverty, violence, substanceabuse, and physical and social disorder. Children with mul-tiple risks benefit most from early childhood developmentinterventions (20 ).
Communities can assess the quality and availability of cen-ter-based early childhood development programs in terms oflocal needs and resources and can use the Task Force recom-mendation to advocate for continued or expanded funding ofearly childhood development programs. Current levels of fed-eral and state funding are not adequate to support accessiblequality services for the number of children at risk who wouldbenefit from participation (21 ). The Task Force recommen-dation can be used as the evidence of effectiveness for thosemaking policy and funding decisions. Health-care providerscan use the recommendation to promote participation in anearly childhood development program as part of well-childcare. Public health agencies can use the Task Force recom-mendation to inform the community regarding the impor-tance of early childhood development opportunities and theirlong-lasting effects on a child’s well-being and ability to learn.
It is beyond the scope of this report to provide “how to”advice on implementing these programs. However, such ad-vice is available through other early childhood developmentstudies and entities (22 ).
Given the complexities of human development, no singleintervention is likely to protect a child completely or perma-nently from the effects of harmful exposures, preinterventionor postintervention. We expect that these interventions willbe most useful and effective as part of a coordinated system ofsupportive services for families (e.g., child care, housing andtransportation assistance, nutritional support, employmentopportunities, and health care) (23 ).
Grassroots organizations, community advocacy groups, andresident stakeholders are in key positions to assess affordablehousing needs within their own communities. Public housingassistance does not reach a large proportion of low-incomefamilies (24 ). An ongoing statewide assessment of housingaffordability, availability, and quality can provide data for com-munity organizations, elected officials, policy makers, andpublic agencies to stimulate the development of resources tomeet local needs.
The Task Force recommendation can be used by publichealth agencies in conjunction with local housing authoritiesto inform policy makers of the effectiveness of rental voucherprograms for increasing family safety in the neighborhoodenvironment. The recommendations could serve as an impe-tus for local health departments, which provide families withcomprehensive services, to assess and monitor the effects ofhousing conditions on health. Working with public health
Vol. 51 / RR-1 Recommendations and Reports 7
Table 3. Recommendations from the Task Force on Community Preventive Services regarding community interventions to promotehealth-enhancing social environments
Task Force Recommendations
Early Childhood Development Programs
Strongly recommended based on improve-ments in children’s cognitive outcomes.
Insufficient evidence† for these outcomes.
Tenant-Based Rental Assistance ProgramsRecommended§ based on lessened crimevictimization.
Outcomes
Academic achievement and IQ scores, graderetention, placement in special education,school readiness.
Behavioral assessments of child’s socialinteraction and social risks (teen pregnancy,teen fatherhood, high school drop-out,unemployment, use of social services,delinquency, arrests, incarceration).
Child health screening, preventive services,dental care.
Parental educational attainment, mother orfather employed, access to health services.
Experience of victimization: crime againstperson (mugged, beaten or assaulted,stabbed, or shot) and property; neighborhoodmurder rate; social disorder: public drinking,public drug use, seeing person carryingweapon, hearing gunfire.
Substandard housing conditions that posehealth and safety risks.
Behavioral problems in school, behavioralproblems at home, delinquent acts, arrests forviolent crime, arrests for property crime.
Self-reported symptoms of depression andanxiety by household head. Self-rated healthstatus as good or excellent compared to fair orpoor. Child needing medical attention foraccidents or asthma, child use of preventiveservices.
Key findings* (reported as standard effectsize or percentage point change)
Cognitive outcomes: median effect size foracademic achievement was +0.35; IQ, +0.43;retention in grade, -21% (from -25% to -2%);special education placement, -12% (from -23%to -6%); and school readiness, +0.34 (12studies).
Social outcomes: median effect size forassessments of child’s social competence was+0.38 and for social risks -0.41(5 studies).
Child health screening: for receipt of healthscreening tests +44%, dental exam within pastyear +61% (1 study).
Family outcomes: median effect size formother high school graduate +4%; father highschool graduate, +3%; family income abovepoverty, +7.4%; mother working, +21.6%;father working, +5.8%; not receiving publicassistance, +16%; and health screening forsiblings of Head Start students +11% (2studies).
Neighborhood safety: median effect size forhousehold member victimized by crime was-6% (from -22% to +6%); neighborhoodmurder rate, -52%; and social disorder,-15.5% (from -89% to -3%) (6 studies).
Housing quality: for presence of peeling paint-53%; inadequate plumbing, -28%; rodentinfestation, -34%; and broken or no locks ondoor to unit, -42% (1 study).
Youth risks: median effect size for youthbehavioral problems was -7.8% (from -8.5% to-7%) (3 studies).
Psychological and physical morbidity: medianeffect size for symptoms of depression andanxiety was -8% (from -9.5% to -6.5%); self-rated health status as good or excellent,+11.5% (from +9% to +11.5%); child requiringacute medical attention, -4.5% (from -6% to0%); and child use of preventive care, -5.5%(from -7% to -4%) (2 studies).
* In studies where means were reported, the effect size calculated is the difference in means between the intervention and the control group, divided by thestandard deviation of the control group. Where percentage point change was reported, the effect size calculated is the difference between the interventionand the control group.
†Evidence can be judged to be insufficient for >1 of the following reasons: limitations in design or execution of the studies, too few studies, inconsistentfindings across studies, or effect size not large enough.
§This intervention is recommended (not strongly recommended) because of the limited number of available studies of suitable design or strong execution.
Insufficient evidence† for these outcomes.
8 MMWR February 1, 2002
and local housing agencies, community-based housing advo-cates and urban planning and community development groupscan advocate for continued and expanded funding for hous-ing resources adequate to sustain family safety and residentialstability and thus support a healthy community.
Additional Information Regardingthe Community Guide
Community Guide topics are prepared and released as each iscompleted. Previously released reviews and recommendationscover population-based interventions to improve vaccinationcoverage and oral health, reduce tobacco use, reduce injuriesto motor-vehicle occupants, improve the health and longevityof persons with diabetes, and increase physical activity. A com-pilation of systematic reviews will be published in book form.Additional information regarding the Task Force, the Com-munity Guide, and a list of published articles is available onthe Internet at http://www.thecommunityguide.org.
References1. Marmot MG, Wilkinson RG. Social determinants of health. Oxford,
UK: Oxford University Press, 1999.2. Yen IH, Syme SL. The social environment and health: a discussion of
the epidemiologic literature. Annu Rev Public Health 1999;20:287–308.
3. Adler NE, Marmot M, McEwen BS, Stewart J, eds. Socioeconomicstatus and health in industrial nations: social, psychological and bio-logical pathways. Ann NY Acad Sci, Vol 896. New York, NY: The NewYork Academy of Sciences, 1999.
4. Anderson L, Fullilove M, Scrimshaw S, et al. A framework for evidence-based reviews of interventions for supportive social environments. AnnNY Acad Sci 1999;896:487–9.
5. Power C, Hertzman C. Health, well-being and coping skills. In: KeatingDP, Hertzman C, eds. Developmental health and the wealth of nations:social, biological, and educational dynamics. New York, NY: GuilfordPress, 1999:41–54.
6. Behrman RE, Vaughan VC III, Nelson WE. Nelson textbook of pediat-rics, 13th edition. Philadelphia, PA: WB Saunders, 1987.
7. Brooks-Gunn J, Duncan GJ, Britto PR. Are socioeconomic gradientsfor children similar to those for adults? Achievement and health of chil-dren in the United States. In: Keating DP, Hertzman C, eds. Develop-mental health and the wealth of nations: social, biological, andeducational dynamics. New York, NY: Guilford Press, 1999: 94–124.
8. Clark RL, King RB, Spiro C, Steuerle CE. Federal expenditures on chil-dren: 1960–1997. Washington, DC: The Urban Institute, 2001.
9. Hertzman, C. Population health and child development: a view fromCanada. In: Auerbach JA, Krimgold BK, eds. Income, socioeconomicstatus, and health: exploring the relationships. Washington, DC: Na-tional Policy Association, 2001:44–55.
10. Currie, J. Early childhood education programs. Journal of EconomicPerspectives 2001; 15(2);213-38.
11. Leventhal T, Brooks-Gunn J. The neighborhoods they live in: the ef-fects of neighborhood residence on child and adolescent outcomes.Psychol Bull 2000;126(2):309–37.
12. Diez Roux AV, Merkin SS, Arnett D, et al. Neighborhood of residenceand incidence of coronary heart disease. N Engl J Med 2001;345(2):99–106.
13. Massey DS, Denton NA. American apartheid: segregation and the mak-ing of the underclass. Cambridge, MA: Harvard University Press, 1993.
14. Wilson WJ. The truly disadvantaged: the inner city, the underclass, andpublic policy. Chicago, IL: University of Chicago Press, 1987.
15. Wood DL, Valdez RB, Hayashi T, Shen A. Health of homeless childrenand housed, poor children. Pediatrics 1990;86:858–66.
16. Institute of Medicine. Homelessness, health and human needs. Wash-ington, DC: National Academy Press, 1988.
17. Briss P, Zaza S, Pappaioanou M, et al., and the Task Force on Commu-nity Preventive Services. Developing an evidence-based Guide to Com-munity Preventive Services —methods. Am J Prev Med2000;18(1S):35–43.
18. Zaza S, Wright-De Agüero LK, Briss P, et al., and the Task Force onCommunity Preventive Services. Data collection instrument and pro-cedure for systematic reviews in the Guide to Community Preventive Ser-vices . Am J Prev Med 2000;18(1S):44–74.
19. Schweinhart LJ, Barnes HV, Weikart DP. Significant benefits: The High/Scope Perry Preschool study through age 27. Monographs of the High/Scope Educational Research Foundation. The High/Scope Press, Edu-cational Research Foundation, Ypsilanti, MI:1993; No. 10.
20. Shonkoff JP, Phillips DA, eds. From neurons to neighborhoods: thescience of early child development. Washington, DC: National Acad-emy Press, 2000.
21. Shumacher R, Greenberg M, Lombardi J. State initiatives to promoteearly learning: next steps in coordinating subsidized child care, HeadStart, and state prekindergarten. Policy Brief. Washington, DC: Centerfor Law and Social Policy, 2001.
22. National Research Council. Early childhood development and learn-ing: new knowledge for policy. Washington, DC: National AcademyPress, 2001.
23. Fuligni AS, Brooks-Gunn J. The healthy development of young chil-dren: SES disparities, prevention strategies, and policy opportunities.In: Smedley BD, Syme SL, eds. Promoting health: intervention strate-gies from social and behavioral research. Washington, DC: NationalAcademy Press, 2000:170–216. Available at http://books.nap.edu/books/0309071755/html/index.html. Accessed September 28, 2001.
24. Nelson KP, Khadduri J, Martin M, Shroder MD, Steffen BL, HardimanD. Rental housing assistance—the worsening crisis. A report to Con-gress on worst case housing needs. Washington, DC: US Departmentof Housing and Urban Development, 2000. Available at http://www.huduser.org/publications/affhsg/worstcase00/worstcase00.pdf.Accessed October 15, 2001.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement ofthese organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for thecontent of pages found at these sites.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Healthand Human Services.
All MMWR references are available on the Internet at http://www.cdc.gov/mmwr. Use the search function to find specific articles.
Task Force On Community Preventive Services*October 1, 2001
Chair: Jonathan E. Fielding, M.D., M.P.H, M.B.A., Los Angeles Department of Health Services, Los Angeles, CaliforniaVice-Chair: Patricia Dolan Mullen, Dr.P.H., University of Texas-Houston, School of Public Health, Houston, TexasMembers: Ross C. Brownson, Ph.D., St. Louis University School of Public Health, St. Louis, Missouri; Mindy Thompson Fullilove, M.D., New York StatePsychiatric Institute and Columbia University, New York, New York; Fernando A. Guerra, M.D., M.P.H., San Antonio Metropolitan Health District, SanAntonio, Texas; Alan R. Hinman, M.D., M.P.H., Task Force for Child Survival and Development, Atlanta, Georgia; George J. Isham, M.D., HealthPartners,Minneapolis, Minnesota; Garland H. Land, M.P.H., Center for Health Information Management and Epidemiology, Missouri Department of Health,Jefferson City, Missouri; Charles S. Mahan, M.D., College of Public Health, University of South Florida, Tampa, Florida; Patricia A. Nolan, M.D., M.P.H.,Rhode Island Department of Health, Providence, Rhode Island; Susan C. Scrimshaw, Ph.D., School of Public Health, University of Illinois, Chicago, Illinois;Steven M. Teutsch, M.D., M.P.H., Merck & Company, Inc., West Point, Pennsylvania; Robert S. Thompson, M.D., Department of Preventive Care, GroupHealth Cooperative of Puget Sound, Seattle, WashingtonConsultants: Robert S. Lawrence, M.D., Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; J. Michael McGinnis,M.D., Robert Wood Johnson Foundation, Princeton, New Jersey; Lloyd F. Novick, M.D., M.P.H., Onondaga County Department of Health, Syracuse, NewYork
* Patricia A. Buffler, PhD., M.P.H., University of California, Berkeley; Mary Jane England, M.D., Regis College, Weston, Massachusetts; Caswell A. Evans, Jr., D.D.S.,M.P.H., National Oral Health Initiative, Office of the U.S. Surgeon General, Rockville, Maryland; and David W. Fleming, M.D., CDC, Atlanta, Georgia, also served onthe Task Force while the recommendations were being developed.
The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) andis available free of charge in electronic format and on a paid subscription basis for paper copy. To receive an electronic copy on Friday ofeach week, send an e-mail message to [email protected]. The body content should read SUBscribe mmwr-toc. Electronic copy also isavailable from CDC’s World-Wide Web server at http://www.cdc.gov/mmwr or from CDC’s file transfer protocol server at ftp://ftp.cdc.gov/pub/Publications/mmwr. To subscribe for paper copy, contact Superintendent of Documents, U.S. Government Printing Office, Washington,DC 20402; telephone (202) 512-1800.
Data in the weekly MMWR are provisional, based on weekly reports to CDC by state health departments. The reporting weekconcludes at close of business on Friday; compiled data on a national basis are officially released to the public on the following Friday.Address inquiries about the MMWR Series, including material to be considered for publication, to: Editor, MMWR Series, Mailstop C-08,CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333; telephone (888) 232-3228.
All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source,however, is appreciated.
IU.S. Government Printing Office: 2002-733-100/69002 Region IV
